- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.78 / $32.78 / $32.78
| Facility | | $32.78 | $32.78 | $32.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.52 / $23.66 / $23.66
| Professional | | $22.52 | $23.66 | $23.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.53 / $18.53 / $18.53
| Facility | | $18.53 | $18.53 | $18.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.82 / $32.63 / $49.08
| Professional | | $18.82 | $32.63 | $49.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.97 / $17.10 / $36.75
| Professional | | $11.97 | $17.10 | $36.75 |